View
215
Download
1
Category
Preview:
Citation preview
3/15/13
1
Intensive Treatment for OCD in Children and Teens
Stephen P. H. Whiteside, PhD, ABPP
Julie Dammann MA, LP
Michael Tiede MA, LP
Overview
Introduction: Why intensive treatment is important
Day 0: Pre-appointment preparation
Day 1: Assessment and Education
Day 2: Getting Started
Day 3 and 4: Exposures and Parent Coaching
Day 5: Wrapping up and post-treatment planning
Conclusions: Future Directions and Questions
2
Introduction Why Intensive Treatment is Important
3
Obsessive-Compulsive Disorder
Symptoms highly heterogeneous Comprised of subtypes
Obsessions (sexual, aggressive, religious, somatic) & checking
Symmetry, ordering, counting, repeating
Contamination obsessions and cleaning compulsions
Hoarding (note: likely a separate disorder in DSM5)
Severe disability associated with condition
4
OCD in children
1 in 200 children and adolescents (Flament, Whitaker, Rapoport, Davies, & et al., 1988; Valleni-Basile et al., 1996)
Chronic 80% of adult cases develop in childhood (Pauls, Alsobrook, Goodman, Rasmussen, & Leckman, 1995)
Exposure and response prevention first-line treatment
(Frances, Docherty, & Kahn, 1997)
6
Meta-Analysis: Effectiveness of Treatments for pediatric OCD
(Abramowitz, Whiteside, & Deacon, 2005)
3/15/13
2
7
Effectiveness of Combined Treatment for Pediatric OCD
CBT CBT & SRIs
Franklin et al., 1998
CY-
BO
CS
TOTA
LS
8
Pediatric OCD Treatment Study Randomized controlled trial
Pre Post
POTS, 2004
CY-
BO
CS
TOTA
LS
Obstacles to treatment
Behavior therapy rarely available, especially ERP (Goisman, & et al., 1993; Goisman, et at., 1999; Grabill et al.,
2007; Kuehn, 2007Storch et al., 2007)
Even CBT practitioners rarely use exposure (Valderhaug, Gotestam, & Larsson, 2004)
Commute long distances to universities and research hospitals for weekly appointments
time and financial constraints
treatment refusal and drop-out
Intensive Treatments
Adult panic disorder (Deacon & Abramowitz, 2006)
2 days
Childhood specific phobia (Ollendick, 2006)
1 day
Child panic (Pincus, Ehrenreich, Suarez, 2007)
8 days
Separation Anxiety (Ehrenreich, Pincus)
1 week
Pediatric OCD Daily appointments over 3 to 4 weeks
Fernandez, Storch, Lewin, Murphy, & Geffken, in press; Franklin et al., 1998; Grabill et al., 2007
Requires considerable time, money and travel
5day Treatment Overview
10 appointments over 5 days
Primary Component: ERP
Inspired by PCIT methodology
Goals: Education on the CB conceptualization of OCD,
its maintenance, and treatment through ERP
Initial symptom reduction through ERP
Build family confidence to continue ERP based on experiences during the treatment
12
3/15/13
3
Retrospective examination of 5day
30 patients, Caucasian
Age
Intensive 11 to 18, m = 13.4 (2.2)
TAU m = 6 to 16, 11.7 (3.2)
Sex
Intensive 53.3% males
TAU m = 60% males
Primarily intact families
parents partial post-secondary education
Primary diagnosis of OCD >= 1 year
IQ > 85
Intensive data published in Whiteside and Brown Jacobsen (2010)
Obsessions and Compulsions Obsessions
Contamination 57% Aggressive 21% Sexual 14%
Compulsions Washing 71% Checking 64% Repeating 57% Counting 36% Ordering/arranging 57%
No hoarding
Outcome
Time F (1, 28) = 198.6, p < .05, Group F (1, 28) = 32.27, p = ns, Interaction F (1, 28) = .23, p = ns
Benchmarking
Study Pre-Tx M (SD) Post-Tx M (SD) F/U % reduction a
POTS (2004) . . . . CBT 26 (4.6) 14.0 (9.5) n/a 46.1% Combined 23.8 (3.0) 11.2 (8.6) n/a 52.9% Barret et al. (2004) . . . . Individual 23.64 (4.3) 8.36 (6.9) n/a 64.6% Storch et al. (2007) . . . . Intensive 25.9 (5.6) 9.5 (6.9) 10.2 (8.7) 60.6% Weekly 25.4 (5.8) 12.8 (8.8) 9.8 (7.6) 61.4% Current Study . . . . TAU 27.13 (5.1) 10.93 (4.2) -- 59.7% Intensive 28.07 (5.4) 16.4 (6.4) 12.93 (5.7) 53.9%
Day 0 Pre-appointment preparation
17
Infrastructure Considerations
Screening process
Dedicated time in calendars
Places patients to stay
Willingness to work with parents
Psychiatry available
Inpatient options
18
3/15/13
4
Patient phone triage
Current obsession and compulsion
Previous treatment and outcome
Medication status
Inclusion criteria: Child motivation for treatment (particularly pre-teen and teen)
Parent willingness to be present for treatment and coach exposures when returning home
Exclusion criteria Severe family conflict
Suicidal ideation
Developmental issues that would interfere with treatment
DBT has been recommended
Psychotic disorder
Not alternative to inpatient/residential
Case example: Tics and family conflict
19
Symptoms
Obsessions that are clearly related to Obsessive Compulsive Disorder
Contamination
Responsible for harm
Unacceptable thoughts
Symmetry, completeness, just right
Compulsions that are related to the obsessions and not other diagnosis (autism, tics)
Washing /Cleaning
Checking, repeating, re-writing, re-reading, seeking reassurance
Praying, confessing, reassurance seeking (self or with others)
Arranging, routines, repeating, redoing, tapping / touching, counting
Ability to address symptoms on location
20
Therapist Qualities
Adequate training in the knowledge and skills necessary to provide mental health services to children and their families
Training in Child development and psychopathology
Social learning and behavior modification
ERP
Other interventions
Capitalize on nonspecific factors Socratic method, avoid jargon, compassion, respect,
confidence, etc
Flexibility
Individual style
21
Therapist Qualities
Balance pressuring the patient to engage in treatment and empathizing with distress Respectful, understanding, encouraging, explicit, and
challenging (Rabavilas et al, 1979)
Calm, composed, unflappable Tolerant and not squeamish Observant Trustworthy Fun and creative Action oriented Willing to let (make) kids be upset
22
Billing
Evaluation
Diagnostic interview: 90791
Treatment
9 sessions- typically 50 minutes
Individual Psychotherapy: 90834
59-distinctly different procedure
23
Day 1 Evaluation, education treatment planning
24
3/15/13
5
Assessment Clinic Structure
Psychology
Questionnaires
Description of problem
Previous Interventions
Structured interview:
Anxiety and common co-morbid conditions (Depression, ADHD, ODD)
Psychiatry
Medications
Medical conditions
Family mental health history
Developmental History
Social History
25
Interview methods
MINI-KIDS
Children Yale Brown Obsessive Compulsive Scale (CY-BOCS)
ADIS-IV (parent & child)
Self-report methods
Spence Children’s Anxiety Scale
CY-BOCS Checklist
Children’s Obsessive-Compulsive Inventory (Foa et al., 2010)
Children’s Florida Obsessive Compulsive Inventory (Storch et al., 2009)
26
Assessment Measures
27
Functional Assessment
Antecedent
Behavior
Consequence
28
Fear evoking stimuli External vs. internal
What happens immediately before Contact vs. spreading
Immediately before event vs. while preparing
Situation Home vs. school or work
Presentations vs. small talk
In bathroom vs. bedroom
FA: Antecedent
29
Erroneous beliefs and interpretations Very bad things are likely to happen
e.g., “I’ll get sick and die”
Emotional reaction
Rituals
All avoidance, escape, safety aids, and strategies used to endure exposure when escape is not possible
Frequency and Intensity
Washing hands for 5 minutes
FA: Behavior
30
What occurs immediately after the behavior? Anxiety decreases
What is sustaining the behavior?
Other people’s reactions Family accommodation
FBA: Consequence
3/15/13
6
Psychoeducation Tools for fighting OCD
Exposures - Face your fears
Response Prevention – Don’t do what OCD tells you to do
Learn how OCD works
Reminder that OCD is the enemy
Teach Mom and Dad to be good teammates
Measure anxiety so it is easier to handle
Recognize the lies that OCD tells you
Be your own cheerleader, don’t help OCD by getting down on yourself
Take it one step at a time. Set goals you can reach
Reward yourself because making changes is hard
31
Why doesn’t anxiety go away
32
Germs
I will get sick
33
What is exposure?
34
The role of Cognitive Restructuring
Purpose: To recognize the lies that OCD tells you and prove them wrong
Do not: Try to modify the obsession itself
Boost confidence for exposures
Learn from exposures
35
I will get sick
Modify: I am going to get sick and I can’t handle not knowing whether I am safe (Bad things are going to happen and I have to know for certain)
Yes, there are germs, we won’t argue that
36
3/15/13
7
Lies that OCD tells me
You shouldn’t have bad thoughts
Thoughts = actions
You have to know for certain
You can’t handle feeling upset
You have to stop bad thoughts
Bad things are going to happen
You have to stop bad things from happening
You have to do things “Just Right
37
Developing a hierarchy
Need to address fear beliefs
Cover body in contamination
Eat while contaminated
Hold child while contaminated
Therapist needs to be comfortable with
Magnified everyday events
Not dangerous activities
Bathroom Fear Ladder
Exposure Rating
Eat food off bathroom floor 9.9
Touch toilet seat 9
Touch toilet flusher 8
Touch door of toilet stall 8
Touch sink faucet 7
Touch towel dispenser in the bathroom 6
Touch bathroom door handle/knob 3
Contaminating Others Fear Ladder
Exposure Rating
Touch a source of contamination then prepare food for others 9 Touch a source of contamination then hug someone who is ill 8 Touch a source of contamination then touch a loved one 7 Touch a source of contamination then someone else’s possessions 7 Touch a source of contamination then give someone a hug 6 Touch a source of contamination then shake hands with someone 5 Touch a source of contamination and then touch public surfaces (door knobs, railings, etc.) 4
Touch a public surface and imagine that your hand has germs and other people will become contaminated. 4
Intrusive Thoughts Fear Ladder
Exposure Rating
Think about mother dying from not walking right 9 Think about father dying form not walking right 7 Think about family member getting sick from not walking right 6 Think about having a bad day from not walking right 5 Think about having therapist dying right now from not sitting right 4 Think about having a bad day from not sitting right 4 Think about having therapist falling down from not sitting right 2 Day 2
Getting Started
42
3/15/13
8
Engaging Kids in Exposures
Psychoeducation
Therapeutic Relationship
Teammates
Humor
Child friendly language and metaphors
Motivators
Games-limited use
Rapport Building
Reward
To make exposures more acceptable for younger children
43
Habituation
Child-friendly language Getting used to the cold water in the pool
Getting used to a dark room
Coasting down a hill
Scary movies
Roller coasters
Disgust as well
Picking up after dog
Chores
Changing diapers
Wagner, 2002
44
Beginning exposure
Exercises to demonstrate like “I can’t walk” and throw paper weight
The situation to practice
Bottom hierarchy
What is OCD telling you will happen
Threat and intolerance of anxiety
What is OCD telling you to do to make yourself feel better
rituals
Anxiety ratings
Distress vs. Urge vs. Dislike
What happened
Fear come true
Anxiety overtime
First without parents, review with parents, then with observing
45
Introducing parent coaching
Be positive and supportive
You are going to find yourself saying the same things over and over, that’s okay
Setting exposure Planing and setting up learning
During exposure Approximately every 2 minutes record anxiety
Help your child realize anxiety is decreasing without rituals
Monitor for rituals
After exposure What learned about fears and anxiety
46
Day 3 and 4 Exposure and Parent Coaching
47
Exposure progression
Setting goals Address each type of symptom
How high up the hiearchy
Child vs. parent
Practicing between sessions
Complete exercise sheets
Sticking to plan
Pace
Follow the child’s lead
Encourage to do the hard items while they are here
Balance encouraging vs.restraining
48
3/15/13
9
In vivo exposures
Contamination
Spreading
Just-right/symmetry
Tapping/touching
Re-reading/re-writing
Harming others/self
knife
49
Types of Imaginal Exposure
Primary Confrontation with unacceptable ideas, images, thoughts (e.g.,
blasphemous, sexual, violent)
Secondary
Exposure to thoughts/doubts evoked by situational exposure (e.g., after situational exposure to being the last person to leave home)
Preliminary As an intermediate step to prepare for situational exposure (e.g., imagine
touching the floor before actually touching the floor)
Why use Imaginal Exposure?
Helps patients learn to confront instead of resist unpleasant intrusive thoughts and memories
By purposely imagining distressing scenes, the individual learns he/she can handle anxiety
They may experience relief of symptoms after listening repeatedly, reinforcing the notion that exposure leads to habituation and symptom reduction
Reduces the need for resistance to thoughts (rituals)
Increases tolerance for uncertainty
Fears of long-term future consequences that cannot be detected immediately can be confronted (brain damage in 30 years)
Fears of not “knowing for sure” can be confronted (you don’t know whether someone repeated the dirty joke you told)
Why use Imaginal Exposure?
Corrects mistaken beliefs about intrusive thoughts and memories
Beliefs about the importance of thoughts
Beliefs about the need to control thoughts and memories
Patient sees that just by allowing him/herself to think of bad things does not make them come true (death of others, sin, other unwanted things)
Patients often gain perspective and see that the ideas that seemed distressing are no longer, and the feared outcomes are unlikely or manageable
Parent coaching
Transfer control from therapist to parent/child
Observe
Record
Set-up
Co-lead
Lead
Generalizing coaching principles
differential attention
small steps
replace avoidance with approach
Meet with parents individually
Balance pushing vs. accommodating
53
Obstacles
Wednesday slump
Patient resistance
Reward system
Teen collaboration plan
Cut-out accommodation
Not anxiety provoking
Practice for game metaphor
Parents factors
Anxiety and OCD
Parent exposure
54
3/15/13
10
Day 5 Wrapping up and Planning for post-treatment
55
Progress review
Progress up fear ladder
Parents independence in last session
Review treatment goals of treatment
Education
Symptom relief
Confidence in coaching (parent/child)
56
Post treatment Planning
Plan for next week Two exposures daily
Written plan
Planned phone calls Monday and Friday
Emails
3 stages
At-home treatment
Working on the fly
Moving on
Relapse prevention
57
Post-tx Obstacles
Child resistance
Busy Schedules
Exposures without parents
Parent noncompliance
Frequent phone calls
Local providers
New symptoms
Other parent/separate households
58
Future Directions
Pilot in other disorders
Complete current research study
Compare to alternative (care at home, weekly)
Enhance with technology
Mayo Clinic Anxiety Coach
Shorter interventions
Questions
59
Recommended